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How did you do that
Enhancing Realism in Patient Simulation
Christopher Scott, Director of Clinical Education & SIMS Medical Center
Michael Foss, Dean – School of Health and Patient Simulation
Assisting – Anna Foss, Dean – Berkshire CC & Brenda Scott, BSN
SPRINGFIELD TECHNICAL COMMUNITY COLLEGE

What is Realism
Realism, Websterʼs way
true and faithful portrayal of nature and of people in
art and literature

What is Realistic
REALITY- A MATTER OF PERCEPTION
Thus the Instructor must have the ability to
manipulate on the fly
As long as participants perceive the environment and
responses as plausible, then the simulation will
remain intact

Factors that are Required for a
Successful Realistic Simulation
Plausible Environment
Familiar Equipment
Plausible Responses
Realistic Simulation
Equipment
Plausible Interactions
Seropian, M. Technology, Computing and Simulation (2003)
Anesth Analg

Fidelity
the quality or state of being faithful b: accuracy in
details : exactness2: the degree to which an electronic
device (as a record player, radio, or television)
accurately reproduces its effect (as sound or picture)
Three Important Fidelities of Patient Simulation
Fidelity
Fidelity
Fidelity

Equipment Fidelity
The degree to which the
simulator duplicates the
appearance and feel of the
real system.
Example: A simulator that
realistically mimics the
layout of an aircraft cockpit.
Our Example: The Labor and
Deliver Nurse walks into a
simulation room that really
looks like a maternity/
birthing suite with realistic
up to date equipment and a
patient with functions that
realistically meet the
objectives.

Environmental Fidelity
The extent to which the simulator duplicates motion
cues, visual cues, and other sensory information from
the task environment.
Example: A flight simulator can be defined as high or low
fidelity depending on whether or not the motion and video
cues were turned on or off.
Our Example – AN ER team walks into a simulation and
while treating the patient, sounds like the C-Med Radio,
overhead pages, and occasional PT Scream, and other
noises/smells are occurring.

Psychological Fidelity
Degree to which the trainee perceives the simulation to be a believable surrogate for
the trained task or real patient encounter
Allows learner to make conceptual sense of the scenario
Generally considered to be the most essential requirement for team training
Our Example – By having participants understand ahead of time the limitations
of simulated patient experiences – aka orientation on the environment/patient –
the students are able to successfully adapt (fiction contract) and work together
to deliver realistic care and obtain quality learning experiences.
Without suspending disbelief trainees are unlikely to behave in the simulation as
they would in the real world! As a result, the training will have little or no
application to the post-training environment.!!
A Typology of simulation fidelity (adapted from Rehmann et al, 1995) #
Beaubien, Baker. Quality and Safety in Health Care, 2004.

Fiction Contract
Is a joint endeavor that students and the instructor/
debriefer create:
The instructor agrees to make the simulation as real as
possible within the resource and technology constraints
Participants agree to do their best to act as if everything is
real. (Suspend Disbelief!)
Instructor will state a fair and balanced assessment of
simulator strengths and weaknesses
AKA – Introduction to Simulator & the environment.

Skillful blending of the three modes of thinking about
realism [environmental, equipment, and psychological]
will allow our trainees to suspend disbelief, or to
actively sign up for the fiction contract that this is a
situation with real relevance for them.
Rudolph et al. Sim Healthcare. 2(3):161-163, Fall 2007.

A successful scenario is
not based on the realism of
the simulation itself, but
rather the alchemy of
participants stepping into
their roles, connecting with
others in the scenario, and
actively linking to their
previous social, clinical, and
psychological experience.
Rudolph et al. Sim Healthcare. 2(3):161-163, Fall 2007.

How did you do that
Examples of realism in Patient Cases

What Makes Realism
Clothes
Makeup
Patient gowns
Street clothes
Sizes – Clothes & shoes
Jaundice
Rashes
Burns
Abrasions and contusions
Diaphoresis
Gender
Wigs
Female Parts
Smells
Feces
Sweat
Vomit
Sounds
C-Med Radios
Phone Systems
Paging Systems
Environment
Up to date equipment
Properly stocked rooms

How do we develop realism
tools/ideas

Designing Realism
-­‐ Background (ques6ons to ask)
• It is important to understand the physiology that is going on
• IE - Developing a wound
– What is the age of the wound
– What environment did the wound occur
• In the field or in the OR
– Do you need to bring in some dirt
– Is the wound infected PUS
– Do we need odors
– Broken Bones Do the bones really bend that way
– Do we needs sound Background noise
– Do we actors

Designing Realism
Develop your own R & D Program
Beta Test Each new item
Does it look real
Does it smell real
Will it withstand the scenario
Will the participants recognize the item as it was intended
to be
Is it cost – Efficient
Can I easily reproduce it

Examples of how we make
realism happen
What we use, what we try not to use, and how we make it
happen!

Items We Use…
Fiber Therapy

Items We Try to Avoid
FOODS/ Products with Sugar!!!
Why – MOLD!!!

If we use food, we use it
externally only!!
Favorites include
Lemon juice & Parmesan Cheese
Limburger Cheese
Okra
Jello / Pudding
Any combo for Feces

Items We use on a daily basis
Sponges
Brushes
Filter Pads
Cutips
Saran Wrap
Rubber Cement !!!
Washable Paints
Powder Based Make ups
Ben Nye Makeup/Wheels
Glycerin
Vaseline
Corn Starch
Metamucil
Stage Blood & Scab Blood
Fake Urine
Liquid Latex (Used Less)

Base Layer
It is important to place a base
layer of protection onto the
simulator to allow for moulage to
be easily removed upon
completion of the scenario(s).

SMELLS

Making “Schkin”

Making “Schkin”

Can we get a volunteer to
make “Schkin”!

So How do we use the Schkin

SCHKIN!
Place enough schkin to area where
you will make injury and blend it
into the the area on simman.

Applying color
Apply necessary color from color
wheels to make injury realistic

Compound Fractures
Same as lacerations
Impale bone
Chicken
Rib
Cotton
Ben Nye Blood
Rubber bands
Coffee stirrers

Gun Shot Wound
Apply schkin
Make a divot in the skin to
represent a bullet hole.
Optional: Place eraser head in
wound to mimic bullet.
Apply ash around area if GSW was at
close range
Use pourable stage blood out of
GSW Wound.

GSW Entrance Wound

GSW Exit Wound

Impalement
Build up Schkin and mold into area
Apply color wheel
Insert impalement into schkin
Apply stage blood as appropriate

Impalement

Road Rash/Abrasion
Use filter sponge and apply color
from color wheel to show road rash
and abriasions

Seat Belt Bruising
Use sponge and filter sponge to apply bruising color wheel in a pattern to
represent an apparent bruise from a seatbelt.

Can we re-create or “mold”
body parts to make
simulations more realistic

Using Molds

How do you develop Sebaceous
Cyst pads
Cost Effective
To purchase from company
over $ 125.oo each
Good only one time!
Number needed for a
single course
At least 12 pads
Answer
Smooth – On
Dragon Skin FX
Able to quickly develop
pads
Cost Effective
Cost Per Pad $ 25.00 for
simman thigh pad and $
18.00 per METI Pad

Products needed from Smooth On
Able to purchase from local Reynolds AM distributors
Items Needed:
Mixing Buckets and Mixing Sticks
Plexiglass
Used to place the molded clay on to allow the smooth cast mold to be poured into and allow for release
of the mold.
Modeling Clay
Used top build a reproduction of the moldable item to have smooth on poured into to make mold or
used to allow for blood pockets to be made in the dragon skin product.
SILC PIG Silicone Pigment
Either 9 pack ( multi-color wheel) or flesh tone, blood, or brown)
Fuse Fx Pro – Warm tan pigment
Mann Release Ease 200
Used to spray the clay to release the mold after pouring the smooth cast 300 into the clay shaped area
that you want to make the reproduction of the item to be molded
Use the spray on the clay that will be placed in the second layer of dragon skin to allow it to be
released from the dragon skin to make the fillable blood area when the second layer dries.
Dragon Skin FX Pro
Mixed with the pigment to make the skin and tissue layers. No mann spray is needed to be used with
the dragon skin unless clay is used.
Smooth Cast 300
Chemical mixed to make a mold of the item to be reproduced.

Mold Making

Spray the objects!! (with Mann Release)

Shaping of Mold

Removing the object

Building a sebaceous cyst and
blood into the mold

Sebaceous Cyst Pads Completed

Abscess
Can Be Incised
Realistic Bleeding
Can add: Pus, Blood, etc
Easily Sutured
Made by pouring dragon skin with pigment
onto plexiglass sheet. When dry Cut into
strips. Then pour clear dragon skin on a
different plexiglass and cutting into
squares when dry. Attach a square to the
middle of the strip of skin using more
dragon skin mixture and a second square
place a small amount of dragon skin on the
outside edges of all sides of the square and
place on top of the same size square
already attached to the skin, thus making a
pocket. Once dry, Use a syringe filled with
blood and slide needle into the pocket via
the side and fill with blood, the pocket
should self seal.

Abscesses

Filling Abscess Packets

Molding of body parts

Alja Safe
Purpose: to make an identical mold of an item, such as
body part
Pros: Cheap, identical match of item
Cons: single to double use only
Items Needed:
Equal parts Alja Safe (from smooth on) to warm water
Mixing stick
Item to be molded
Item to house mold ( what you will make the mold in

Using Alja Safe

Re-creating molded item
Once molded item is removed inspect the mold.
Decide what the color of the item is you want to make
the identical mold out of
Use appropriate amount of dragon skin equal parts A &
B with selected color mixed into part B of the dragon
skin from the silc pig
Once thoroughly mixed, pour mixture into mold and let
sit for the appropriate cure time ( usually one hour)
Gently remove molded item from the mold.

Suture Pads

Items needed for Suture Pads
Piece of plywood
Textured vinyl fabric (to make skin like texture)
Glue gun (to adhere vinyl to plywood)
Pressure Clamps
Eco flex 00-30 (available from smooth – on)
Eco flex Gel (available from smooth – on)
Power Mesh (available from smooth – on)
Silc Pig ( for Coloring) (available from smooth – on)

Making of the suture pads
First adhere the vinyl to the plywood with glue
Clamp power mesh to the vinyl board
Mix equal parts of ecoflex 00-30 with the silc pig flesh color and stipple into mesh in a
square area
Let dry x 1 hour
Mix equal parts of Ecoflex Gel with yellow color from silc pag and pour on top of skin
layer, creating fat layer that is more gelatinous.
let dry x 1 hour
Mix equal part of eco – flex 00-30 with blood/muscle color from silc pig and pour on top
of yellow layer
Let dry x 1 hour
Remove item and cut to shape.

Wound Making

Other inexpensive items to make

Broken Glass (the safe way)

Broken Glass (part two)

Ooze!! ( AKA drainage, mucous)

Intestines

Making Feces
Vaseline, Cornstarch, Brown Paint

Molding Feces

Making Diarrhea

Making Diarrhea

Other great Realism
Examples

Frostbite
Use black eye shadow
Fade in with white
Jimmy Rowland

Partial Thickness Burn

Partial Thickness Burn
Red saran wrap
Liquid latex or Schkin
Burn Color wheel
Glycerin or Vaseline for shine

Examples of Burns/Blisters
Apply liquid latex from Ben Nye to
an area where you would like a
burn/blister to appear.
Let Air Dry to a dry/tacky
consistency

Designing of Burn
Once to a dry/slightly tacky
consistency, use cue tip to pull
areas of the liquid latex apart to
make appearance of burn/sliding
skin.

Apply blood from color wheel and ash/charcoal to
wound, cover with petroleum Jelly

Making Maggot Foot

Maggot Foot

Cleaning Supplies

Ben Nye Kit

Resources
www.cert-­‐la.com/educa/on/moulage-­‐recipes.pdf
www.behindthesimcurtain.com
www.whatcomcountyems.com/pdfs/CE%20Instructors/BASIC
%20MOULAGE.pdf
www.moulageconcepts.com
www.sickkitchen.com
MOLD Making – Dragon Skin
www.smooth-­‐on.com
www.reynoldsam.com

Some Examples
Just some examples of what you can do
hHp://www.shopanatomical.com/
Casualty_Simula6on_Moulage_s/14234.htm
www.moulage.net
www.prankpalace.com
hHp://www.stagemakeuponline.com/
www.pocketnurse.com
www.wallcur.com